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Clinical and neurophysiological aspects of spinal manipulation

Manipulations (HVLA) techniques consist of fast and precise mobilizations applied to one articular segment in its physiological range of motion, without crossing the anatomical boundary of the joint. 

HVLA translates to H-high, V-velocity, L-low, and A-amplitude. 

Classical manipulation with HVLA techniques, when there are no contraindications, allows us: 

  1. Release of endorphin, a neurotransmitter produced by the pituitary gland that has a strong anti-inflammatory effect and also relieves pain
  2. Pain reduction by neural reflexes 
  3. Articular stress relief and to a lesser extent mechanical effects
The review of the literature concludes clear neurophysiological changes following spinal manipulation that include:
  • neuroplastic changes 
  • changes in motor-neural apparatus
  • increased cortical drive 
  • and many others
However, the clinical relevance of these changes due to the mechanisms triggered by spinal manipulation is still unknown.
Physiotherapist Adnan Kojić
Contraindications to manipulation

Absolute contraindications for HVLA manipulations

Absolute contraindications (bone):

  • all pathological conditions that weaken bones
  • tumors 
  • infections
  • metabolic diseases 
  • congenital bone deformities
  • long-term use of corticosteroids
  • inflammatory bone diseases
  • traumatic bone injuries
Absolute contraindications (neurological):
  • cervical myelopathy (compression of the spinal cord due to compression or ischemia)
  • spinal cord compression
  • cauda equina compression
  • nerve root compression with neurological deficits 

Absolute contraindications (vascular):

  • diagnosis of vetrebro basilar insufficiency (VBI)
  • aneurysm
  • tendency to bleed 

Relative contraindications

Relative contraindications for manipulations are:

  • side effects during previous HVLA manipulations 
  • inflammatory arthritis 
  • pregnancy
  • osteoporosis
  • long-term use of anticoagulants or corticosteroids 
  • herniated disc 
  • spondylosis 
  • spondylolistesis
  • vertigo
  • psychological dependence on HVLA manipulation 
  • above average ligamentous flexibility
  • calcification in the arteries  
Manipulation of the spine
The Golgi's tendon organ

Myotatic and reverse mytotatic reflex

Myotatic reflex or a stretch reflex is a contraction in response to passive stretching that increases contractility as long as the stretching is within physiological limits. 

For years, the myotatic reflex was considered the same as the tendon reflex.

Reverse myotatic reflex is contrary to myotatic reflex. This reflex connects the great force in the Golgi tendon organs with relaxation. In it, stretching eliminates the reflex of contraction. 

Although this reflex is called the reverse myotatic reflex, it is not necessary to stretch the muscle for activation. 

Using mobilization, massage, physical modalities and instruments, IASTM, exercises, stretching, etc. it is possible to influence defensive locks that occur due to the mechanism explained above (myotatic reflex). It is affected by working on individual muscles, tendons, ligaments, joints, but you will need much more time and effort. Using these methods, it is not possible to activate the reverse Myotatic reflex (Golgi).


Interoception refers to the representation of the internal world within us. It involves the processes in which the organism senses, interprets, integrates and regulates signals within itself. 

The brain communicates with internal organs through the peripheral nervous system and other non-neurological systems. 

The main components of the joint research project on interoception include interoceptive signals, interoceptors, ascendant and descendant integrators, central regulators, and interoceptive effectors. 

Detailed mechanical research into the relationship of anatomy with function is essential in understanding the role of the elements of interoception. 

History of manipulation

The origin of the HVLA thrust manipulation technique

A spinal manipulation is a form of therapy that has existed since ancient times. The earliest historical evidence known to us dates back to Ancient Greece around 400 BC. Spinal manipulation can be seen in Traditional Medicine in Indonesia, India, and pretty much all of Asia, as well as in northern parts such as Russia and Norway over 4000 years in history. 

Hippocrates wrote about manual thrust manipulations in reducing dislocations to treat various health problems. If this name sounds familiar to you, the Hippocratic Oath is something that all medical doctors take to maintain the principles and proper application of the medical profession. 

Although no one questions the origin or origin of manipulative therapy, it has only been since 19.- in the 20th century, according to the present day, manipulative therapy is trying to be appropriated by some professions. In order to truly understand the role of manipulative therapy, every profession of medicine, chiropractic, osteopathy and the most important physical therapy must be studied, as well as the history of the use of manipulations in each of them individually. 

Unprofessional behavior by some groups in each of these professions with the intention of owning one of the manual techniques can be solved precisely by studying the history and application of HVLA thrust manipulations by professionals with different scientific backgrounds and thus put an end to attempts to appropriate and authorize something that does not belong to them. 

Bsc. PT. Adnan Kojić

Bsc. PT. Adnan Kojić

Adnan is bacc. physiotherapy, who works in his practice in Montenegro, focuses on manipulation (HVLA) and teaches the same techniques to physiotherapists around the world with one of the world's most famous osteopaths, Dr. Giovanni Bonfanti.

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